Endometriosis

What is endometriosis?

Endometriosis is the abnormal growth of cells (endometrial cells) similar to those that form the inside or lining the tissue of the uterus, but in a location outside of the uterus. Endometrial cells are cells that are shed each month during menstruation. The cells of endometriosis attach themselves to tissue outside the uterus and are called endometriosis implants. These implants are most commonly found on the ovaries, the Fallopian tubes, outer surfaces of the uterus or intestines, and on the surface lining of the pelvic cavity.They can also be found in the vagina, cervix, and bladder, although less commonly than other locations in the pelvis. Rarely, endometriosis implants can occur outside the pelvis, on the liver, in old surgery scars, and even in or around the lung or brain.

Symptoms of Endometriosis?

Endometriosis can present by different presentation. A woman who have endometriosis, may have no symptoms. Of those who do experience symptoms, the common symptoms are pain (usually pelvic pain ) and infertility. Pelvic pain usually occurs during or just before menstruation and lessens after menstruation. Some women experience painful sexual intercourse (dyspareunia) or cramping during intercourse, and or/pain during bowel movements and/or urination. Even pelvic examination by a doctor can be painful. The pain intensity can change from month to month, and vary greatly among women. Some women experience progressive worsening of symptoms, while others can have resolution of pain without treatment.

Pelvic pain in women with endometriosis depends partly on where the implants of endometriosis are located.

Deeper implants and implants in areas with many pain-sensing nerves may be more likely
to produce pain.
he implants may also produce substances that circulate in the bloodstream and cause
Lastly, pain can result when endometriosis implants form scars. There is no relationship between severity of pain and how widespread the endometriosis is (the “stage” of endometriosis).

Endometriosis can be one of the reasons for infertility for otherwise healthy couples. When laparoscopic examinations are performed for infertility evaluations, endometrial implants can be found in some of these patients, many of whom may not have painful symptoms of endometriosis. The reasons for a decrease in fertility are not completely understood, but might be due to both anatomic and hormonal factors. The presence of endometriosis may involve masses of tissue or scarring (adhesions) within the pelvis that may distort normal anatomical structures, such as Fallopian tubes, which transport the eggs from the ovaries. Alternatively, endometriosis may affect fertility through the production of hormones and other substances that have a negative effect on ovulation, fertilization of the egg, and/or implantation of the embryo.

Other symptoms that can be related to endometriosis include:

lower abdominal pain,
diarrhea and/or constipation,
low back pain,
chronic fatigue
irregular or heavy menstrual bleeding, or
blood in the urine.

Rare symptoms of endometriosis include chest pain or coughing blood due to endometriosis in the lungs and headache and/or seizures due to endometriosis in the brain.

Incidence of endometriosis?.

Estimates suggest that between 20% to 50% of women being treated for infertility have endometriosis, and up to 80% of women with chronic pelvic pain may be affected. Endometriosis is rare in postmenopausal women.

Who is effected?

Endometriosis effects women in reproductive years . Most cases of endometriosis are diagnosed in women aged around 25 to 35 years. It can occur in teen age girls but rare in menopausal women.

What causes endometriosis?

The exact cause of endometriosis is unknown. One theory is that the endometrial tissue is deposited in unusual locations by the backing up of menstrual flow into the Fallopian tubes and the pelvic and abdominal cavity during menstruation (termed retrograde menstruation). But retrograde menstruation cannot be the sole cause of endometriosis. .Another possibility is that areas lining the pelvic organs possess primitive cells that are able to grow into other forms of tissue, such as endometrial cells. (It is also likely that direct transfer of endometrial tissues during surgery may be responsible for the endometriosis implants sometimes seen in surgical scars (for example, episiotomy orCesarean section scars). Transfer of endometrial cells via the bloodstream or lymphatic system is the most likely explanation for the rare cases of endometriosis that develop in the brain and other organs distant from the pelvis . Finally, there is evidence that shows alternations in the immune response in women with endometriosis.

How the diagnosis of endometriosis is made?

Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examination. Its important that neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound, can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. For an accurate diagnosis, a direct visual inspection inside of the pelvis and abdomen, as well as tissue biopsy of the implants are necessary. As a result, the only accurate way of diagnosing endometriosis is laparoscopy.

How is endometriosis treated?

Endometriosis can be treated by medical , surgical or combined medical & surgical.

The goals of endometriosis treatment may include pain relief and / or enhancement of fertility.

Laparoscopic Treatment of Endometriosis

Laparoscopy is the gold standard for the diagnosis of endometriosis i.e. the diagnosis of endometriosis is confirmed by laparoscopy. Laparoscopy is a surgical procedure done under general anesthesia. During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis.

The adhesions (bands of tissue that make organs stick together) are seprated at laparoscopy and Endometriomas (Blood filled endometriotic ovarian cysts) are treated, and normal uterine, tubal and ovarian relationship established, any endometriotic deposits found in the pelvis are also removed.

Medical treatment of endometriosis

Medical treatment includes Nonsteroidal anti-inflammatory drugs to relieve pelvic pain and menstrual cramping. Because the diagnosis of endometriosis is only definite after a woman undergoes surgery.

Since endometriosis occurs during the reproductive years, many of the available medical treatments for endometriosis rely on interruption of the normal cyclical hormone production by the ovaries. These medications include GnRH analogs, oral contraceptive pills, and progestins.

Gonadotropin-releasing hormone analogs (GnRH analogs)

Gonadotropin-releasing hormone analogs (GnRH analogs) have been effectively used to relieve pain and reduce the size of endometriosis implants. These drugs suppress estrogen production by the ovaries by inhibiting the secretion of regulatory hormones from the pituitary gland. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available (Zoladex, Leuprolide).

The side effects are a result of the lack of estrogen, and include:

Hot flashes,
Vaginal dryness,
Irregular vaginal bleeding,
Mood changes,
Fatigue, and
Loss of bone density (osteoporosis).

Fortunately, by adding back small amounts of estrogen and progesterone in pill form (similar to treatments sometimes used for symptom relief in menopause) many of the annoying side effects due to estrogen deficiency can be avoided. “Add back therapy” is the term that refers to this modern way of administering GnRH agonists along with estrogen and progesterone in a way to keep the treatment successful, but avoid most of the unwanted side effects.

Oral contraceptive pills

Oral contraceptive pills (estrogen and progesterone in combination) are also sometimes used to treat endometriosis. The most common combination used is in the form of the oral contraceptive pill (OCP). Continuous use in this manner will free a woman of having any menstrual periods at all. Occasionally, weight gain, breast tenderness, nausea, and irregular bleeding are mild side effects. Oral contraceptive pills are usually well-tolerated in women with endometriosis.

Progestins

Progestins [for example, medroxyprogesterone acetate, norethindrone acetate, norgestrel acetate ] are more potent than birth control pills and are recommended fin selected who do not obtain pain relief from or cannot take a birth control pill.

Side effects are more common and include:

Breast tenderness, bloating, weight gain, irregular uterine bleeding and depression.

Danazol

Aromatase inhibitors

These drugs act by interrupting local estrogen formation within the endometriosis implants themselves. They also inhibit estrogen production in the ovary, brain, and other sources, such as adipose tissue. Aromatase inhibitors cause significant bone loss with prolonged use and cannot be used alone without other medications such as GnRH diagonists or combination of oral contraceptives in premenopausal women because they stimulate development of multiple follicles at ovulation.